Mouthcare for ELDERS in Residential Care - UBC Geriatric ...

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Mouthcare for ELDERS in Residential Care - UBC Geriatric ...
Mouthcare
                                          for ELDERS in
                                              Residential
                                                   Care

                                                                    Second Edition

Elders’Elders’ LinkDental
        Link with   with Dental Education,
                          Education,         Research,
                                      Research,         & Service
                                                   & Service
      Faculty  of Dentistry, University of British Columbia
Faculty of Dentistry, University of British Columbia                     Copyright 2006
Mouthcare for ELDERS in Residential Care - UBC Geriatric ...
INTRODUCTION                                                             1
                           FORWARD
                           Oral health is an important aspect of the general health and
                           well-being of seniors. With older adults keeping their natural
                           teeth longer than ever before, this updated manual provides an
                           invaluable resource for caregivers to meet the daily oral care
                           needs of seniors. However, there still remains challenges to
                           ensuring seniors, particularly the vulnerable and less mobile,
                           have access to regular oral care. BC’s dentists are committed to
                           developing and implementing solutions in collaboration with key
                           stakeholders, such as dental hygienists, to provide BC’s aging
                           population access to quality oral care services.

                           		                 Dr. Tony Gill, President,
                           		                 BC Dental Association

                           INTRODUCTION
                           Daily mouthcare for people who are frail and dependent is a
                           challenge for dentists, dental hygienists, dental assistants and
                           denturists. It is no less difficult for nurses, care-aides, family
                           members and everyone else who attend to the well-being of
                           others. Ironically, the challenge has increased in direct proportion
                           to the success of public health initiatives that preserve natural
                           teeth. Today, most people have natural teeth, frequently supported
                           by dentures and occasionally with oral implants. Consequently,
                           daily mouthcare has changed from the simple task of rinsing off
                           dentures to the more difficult tasks of removing sticky microbial
                           plaque from natural teeth, and identifying early signs of disease
                           that threaten general health and quality of life. This manual is for
                           care-aides and others who attend to and/or supervise the daily
                           care of frail elders. It explains and illustrates the essentials of oral
                           hygiene and other mouthcare procedures to reduce the risk of
                           infection and to enhance health, cleanliness and dignity in old age.

Elders’ Link with Dental Education, Research, & Service
Faculty of Dentistry, University of British Columbia
Mouthcare for ELDERS in Residential Care - UBC Geriatric ...
GETTING STARTED                                                                2
                            WHY SHOULD THE MOUTH
                               BE CLEANED EVERY DAY?
                            Plaque forms as a sticky film of harmful bacteria on teeth, on the lining
                            of the mouth and on dentures. Some bacteria produce poisons that
                            cause bleeding gums and bad breath. When the bacteria in plaque are
                            fed sugar from candies, sweet drinks or other soft carbohydrates, they
                            produce acids that cause cavities in teeth. Plaque should be cleaned
                            from the mouth every day to prevent tooth decay, bleeding gums and
                            bad breath.

                            SUGAR
                            Sucrose in the form of refined sugar and carbohydrates negatively
                            affects oral health. Sweets (cakes, cookies, candies), soft drinks and
                            fruit juices can be particularly damaging to teeth because of high
                            sugar content. The sugar is turned into acid by bacteria on the teeth,
                            and if the acid is not neutralized quickly or the bacteria removed, they
                            will create cavities. It takes about 40 minutes to neutralize the acid
                            after consuming a sweet drink or snack, therefore sugar consumption
                            between meals is particularly destructive.

                            ROLE OF THE CAREGIVER
                            Persons in residential care should be encouraged as much as possible
                            to attend to their own mouthcare. Only rarely will residents complain
                            about their mouthcare. Toothbrushing is a more complicated task than
                            dressing. If residents have limited dexterity, poor eyesight, dementia or
                            depression, they may require help with daily mouthcare.

                            Personal neglect should be suspected if there has been a break in
                            the daily mouthcare routine or a change in eating habits, and more
                            particularly if the teeth or dentures trap food, or if the resident has bad
                            breath. When a problem is suspected, it is best to offer assistance with
                            mouthcare.
                            If the gums bleed easily, it probably means that the teeth need to be
                            brushed more frequently and extensively to remove plaque that sticks
                            to tooth surfaces.
                            Ask the resident occasionally if they are suffering from toothaches or
                            mouth discomfort. If a problem is found or suspected, bring it to the
                            attention of a dental professional so that it can be diagnosed and treated
                            appropriately (see page 13).

Elders’ Link with Dental Education, Research, & Service
Faculty of Dentistry, University of British Columbia
Mouthcare for ELDERS in Residential Care - UBC Geriatric ...
DAILY MOUTHCARE                                                             3
                            REMOVING PLAQUE
                            The usual tools for cleaning the mouth are toothbrushes (manual or
                            electric), toothpaste and, if possible, dental floss (see page 14).
                            Only effective mouthcare (brushing and flossing) will remove sticky
                            plaque. Rinsing with a mouthwash may reduce the harmful effects of
                            the bacteria but it will not remove plaque. However mouthwash with
                            fluoride can prevent tooth decay.

                            Dentures should be removed before brushing the teeth and they should
                            also be brushed thoroughly every day. It is wise to clean them over
                            a sink full of water to prevent breakage if the denture is accidentally
                            dropped.

                            A good light and a little practise manipulating the lips, cheeks and
                            tongue will improve access around the mouth to see that the plaque is
                            being removed. A tongue depressor can be used to keep the tongue or
                            cheeks out of the way when cleaning the back teeth.

                            It is best to clean the mouth just before the resident goes to bed. This
                            will decrease the exposure of the teeth and gums to the plaque bacteria
                            overnight when the natural protective flow of saliva decreases.

                            To prevent the spread of infection, disposable gloves should be worn
                            when cleaning the mouth. Toothbrushes should never be shared
                            among residents!

Elders’ Link with Dental Education, Research, & Service
Faculty of Dentistry, University of British Columbia
Mouthcare for ELDERS in Residential Care - UBC Geriatric ...
POSITION THE RESIDENT 4
                                Correct posture is important for access to the mouth, for
                                comfort of the resident’s head and neck, and for protecting
                                the caregiver’s back.

                                Access to the mouth of a resident in a wheelchair can be
                                obtained by standing behind the resident to support the
                                head and neck.

                                When the resident is lying down, it may be more
                                comfortable for the caregiver if the resident is approached
                                from above and behind or from the side after adjusting
                                the height of the bed.

                                You may have to experiment to find a position that
                                is comfortable for both you and the resident.

Elders’ Link with Dental Education, Research, & Service
Faculty of Dentistry, University of British Columbia
Mouthcare for ELDERS in Residential Care - UBC Geriatric ...
TOOTH CLEANING                                                          5
                                Rinse the toothbrush with warm water and place a small
                                amount of toothpaste on the bristles.

                                Place the bristles of the brush on the tooth and massage
                                back and forth to remove the plaque from all the surfaces.

                                Plaque tends to collect on the roots of teeth along the gum
                                line. Therefore, it is important to brush both teeth and
                                gums.

                                Move around the mouth in sequence, to contact all of
                                the teeth.

                                Finally, rinse the mouth with water. A moistened cotton
                                gauze can be used to wipe the mouth if a resident cannot
                                spit.

Elders’ Link with Dental Education, Research, & Service
Faculty of Dentistry, University of British Columbia
Mouthcare for ELDERS in Residential Care - UBC Geriatric ...
FLOSSING                                                               6

                               Floss comes in many forms (unwaxed, waxed and yarn).
                               Select the one that works best for you and the resident.

                               Take a 40-50 cm piece of floss; wind it around the middle
                               fingers of each hand. Control with index fingers or thumb
                               5 cm of floss so that it can pass comfortably and flexibly
                               between the teeth.

                               The plaque is removed by moving the floss up and down
                               against the surfaces of each tooth.

                               Make sure each “in-between” surface of the teeth is
                               flossed, and that the floss passes up and down, cleaning the
                               tooth’s surface. Floss should not be shared and should be
                               thrown away after each use.

Elders’ Link with Dental Education, Research, & Service
Faculty of Dentistry, University of British Columbia
Mouthcare for ELDERS in Residential Care - UBC Geriatric ...
SPECIAL AIDS                                                         7
                               INTERPROXIMAL BRUSHES

                               Interproximal brushes are small brushes used to clean the
                               surfaces between teeth.

                               Insert the brush between teeth, and clean with an in-and-
                               out motion. The brushes do wear out so they must be
                               replaced, but they can be rinsed off and reused when still
                               in good shape.

                               FLOSS HOLDERS

                               The addition of a handle may make it easier for people
                               to floss. There are several designs, some with disposable
                               heads and others with spools of floss.

                               Use the floss holder in a similar manner to finger
                               flossing.

Elders’ Link with Dental Education, Research, & Service
Faculty of Dentistry, University of British Columbia
Mouthcare for ELDERS in Residential Care - UBC Geriatric ...
GUM CLEANING                                                    8

                                The gum around teeth or under dentures should be
                                cleaned with a brush every day.

                                A toothbrush moistened with water can be used to massage
                                the gums, the roof of the mouth and the tongue. This
                                action removes food debris, improves blood circulation
                                and prevents bad breath.

                Rinsing with water or mouthwash does not clean the mouth adequately.

Elders’ Link with Dental Education, Research, & Service
Faculty of Dentistry, University of British Columbia
Mouthcare for ELDERS in Residential Care - UBC Geriatric ...
DENTURE CLEANING                                                        9
                               The dentures should be removed from the resident’s mouth
                               and brushed thoroughly at least once a day. Cleaning the
                               inside surface of the denture is very important! Brush the
                               dentures over a sink filled with water to prevent damage if
                               the denture is accidentally dropped. In addition, dentures
                               should be rinsed after each meal to remove food
                               remnants. A clean denture is more easily tolerated by the
                               resident and is more healthy.

                               A toothbrush will remove plaque and food remnants
                               effectively from dentures, teeth and the soft lining of the
                               mouth.

                               A soft toothbrush, denture brush, or a new nailbrush can
                               be used with liquid soap and warm water to brush all
                               surfaces of the denture. Avoid abrasive cleansers, including
                               toothpaste, that can roughen the polished surface of the
                               denture.

                               Usually it is better not to wear dentures while sleeping.
                               However some residents prefer to wear their dentures
                               day and night. If this is the case, special care is needed to
                               ensure that the area under and around the dentures is kept
                               very clean.

                               Dentures should be dry when not in the mouth and
                               stored in a container with the resident’s name.

Elders’ Link with Dental Education, Research, & Service
Faculty of Dentistry, University of British Columbia
SPECIAL CARE                                                        10
                                BLEEDING GUMS
                                Inflammation of the gums (gingivitis) occurs usually
                                because mouthcare has not removed sticky plaque from
                                the teeth.

                                If plaque is not removed daily, the gums will continue to
                                bleed. Daily tooth brushing must continue even when the
                                gums bleed. If the bleeding persists without improvement
                                for more than a week, contact a dental professional (see
                                page 13).

                                RESISTANT RESIDENTS
                                Resistant behaviour may be a sign that the resident is
                                in pain, especially if the behaviour is unusual.

                                For a resident who clenches or who refuses to open the
                                mouth, the outer surfaces of the front teeth can be cleaned
                                by parting the lips with gentle but firm pressure. Brush
                                some of the teeth each day so that the resident will be
                                encouraged to cooperate. Select a time of day when the
                                resident is most agreeable. What does not work one day
                                may work on another day.

                                AVOIDING BITES
                                Attention is needed if a resident seems uncooperative or
                                anxious. Biting may be an indirect way of expressing a
                                desire to be left alone! It may be preferable to postpone
                                mouthcare until the resident is more relaxed. In any event,
                                never place your fingers between the upper and lower
                                teeth. A mouth prop can be placed between the teeth if the
                                resident is unable to keep the mouth open.

Elders’ Link with Dental Education, Research, & Service
Faculty of Dentistry, University of British Columbia
SPECIAL CARE                                                         11
                                CARING FOR A DRY MOUTH
                                Saliva plays a vital role in keeping the teeth, gums and
                                lining of the mouth healthy. There are many medications that
                                will reduce the flow of saliva. The attending physician and
                                dentist should be advised if the resident appears to have a
                                particularly dry mouth.
                                In the event that dryness of the mouth persists, there are a
                                few precautions that must be taken to prevent tooth decay
                                and to ease discomfort.

                                  The resident should avoid all foods and drinks containing
                                  sugar and they should use a mouthrinse with fluoride
                                  every day.

                                  Under no circumstances should a resident continuously
                                  sip a sweetened drink to moisten a dry mouth because of
                                  the extreme risk of tooth decay.

                                  Use a fluoride containing toothpaste to clean the
                                  residents’s teeth at least once a day.

                                  Lubricate dry lips during mouthcare to reduce discomfort
                                  and further cracking.
                                  Avoid using products containing alcohol, lemon or
                                  glycerin, as they make a dry mouth even drier.

Elders’ Link with Dental Education, Research, & Service
Faculty of Dentistry, University of British Columbia
SPECIAL CARE                                                         12
                                UNCONSCIOUS RESIDENT
                                Special precautions should be taken to keep the mouth
                                open and to prevent the resident from choking while
                                cleaning the mouth.

                                To keep the mouth open, use a mouth prop. There are
                                several commercial mouth props available, and they can
                                be washed in the dishwasher and reused.

                                You can make a mouth prop by placing two or three
                                wooden tongue blades together. Wrap several 2 x 2 gauze
                                squares around the top half and secure the gauze in place
                                with tape.

                                Lubricate dry lips to prevent cracking when the mouth
                                is propped open. Turn the head to the side and place the
                                prop in the mouth on the side closest to the pillow to allow
                                access to the other side of the mouth.

                                To prevent choking, allow the resident to lie sideways so
                                that saliva and other fluids will flow out of the mouth. Use
                                suction if available and cottons swabs or towels to control
                                the fluids.

                                Clean the side of the mouth that is not resting on the
                                pillow. Reposition the resident and clean the other side of
                                the mouth. Soak up excess moisture with gauze or a towel.

Elders’ Link with Dental Education, Research, & Service
Faculty of Dentistry, University of British Columbia
MOUTHCARE DECISIONS FOR
           CAREAIDS                                                                           13
                               DAILY ORAL INSPECTION

       NO CONCERNS                                                      CONCERNS

                      BLEEDING STOPS
                                                  BLEEDING GUMS                   OTHER CONCERNS
                                                perform daily mouth                pain, bad breath,
                                                cleaning for one week            broken teeth, refusing
                                                                                 mouthcare, change in
                                                                                     eating habits
                                               BLEEDING CONTINUES

                                                                     RECORD & REPORT

                                                                          REFER TO
CONTINUE WITH DAILY MOUTH CARE
                                                                  ORAL HEALTH PROFESSIONAL

        Elders’ Link with Dental Education, Research, & Service
        Faculty of Dentistry, University of British Columbia
MOUTHCARE PRODUCTS 14
                           MOUTH
                           			   CARE SUPPLIES
                             Soft-bristled toothbrush               ADDITIONAL AIDS
                             Fluoride containing toothpaste         Interproximal brushes
                             Denture brush 			                      Floss holders
                             Disposable gloves                      Electric toothbrushes
                             Lip lubricant                          Fluoride mouthrinse
                             Washcloth                              Mouth moisturizer
                             Glass of water (and straw)
                             Small emesis basin
                             Denture cup

                           STORAGE
                           All mouthcare products for each resident (toothbrushes, toothpaste,
                           mouthrinse, denture cups) should be stored separately in a designated
                           area that is appropriately labelled and visible.

                           Toothbrushes and denture brushes should be labelled, dated and stored
                           upright (e.g., in a cup). Toothbrushes should be changed every 3
                           months and after upper respiratory infections.

                           DENTAL PRODUCT SUPPLIERS
                           Biotene 			                        Johnson & Johnson
                           1-800-922-5856			                  www.jnj.com
                                                              �����������
                           www.biotene.net
                           (Oralbalance mouth moisturizer)

                           Colgate-Palmolive Canada Inc.      Oral B Laboratories
                           1-800-268-6757                     www.oralb.com
                           www.colgate.ca

                           E-Z Floss                          Specialized Care Co.
                           1-800-227-0208                     1-800-722-7375
                           www.e-zfloss.com                   www.specializedcare.com

                           The John O. Butler Company         Waterpik technologies Inc.
                           www.jbutler.com                    www.waterpik.com

Elders’ Link with Dental Education, Research, & Service
Faculty of Dentistry, University of British Columbia
CREDITS                                                                15
                                    Authors
                                    Chris Wyatt, BSc, DMD, MSc, FRCD(C).
                                    Michael MacEntee, LDS, Dip Pros, FRCD(C), PhD.

                                    Funding Provided By
                                    Faculty of Dentistry
                                    University of British Columbia,
                                    2199 Wesbrook Mall, Vancouver, BC V6T 1Z3
                                    tel: (604) 822-3564           fax: (604) 822-3562

                                    British Columbia Dental Association
                                    Suite 400 – 1765 West 8th Avenue
                                    Vancouver, BC V6J 5C6
                                    tel: (604) 736-7202          fax: (604) 736-7588

                                    The College of Dental Hygienists of British Columbia
                                    Suite 219, Yarrow Building, 645 Fort Street
                                    Victoria, BC V8W 1G2
                                    tel: (250) 383-4101           fax: (250) 383-4144
                                    1-800-778-8277 Toll Free within BC
                                    www.cdhbc.com

                                    Ministry of Health
                                    Ministry of Employment and Income Assistance
                                    www.gov.bc.ca

                                    Acknowledgments
                                    We wish to thank Anne-Marie Skolaude for organizing the
                                    content and images of this manual. Also we thank
                                    the following for reviewing the educational material:
                                        UBC Geriatric Dentistry Program dental hygienists
                                          Leeane Donnelly, RDH, BDSC, MSc
                                          Ashif Dharamsi, RDH, ID
                                          Shafik Dharamsi, RDH, PhD
                                          Janice Williams, RDH, BSc

Elders’ Link with Dental Education, Research, & Service
Faculty of Dentistry, University of British Columbia
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